Skip to main content
Log in

Bailout left atrial appendage occluder for pulmonary vein isolation and electrical cardioversion in patients with atrial fibrillation and left atrial appendage thrombus: a pilot study

  • Original Paper
  • Published:
Clinical Research in Cardiology Aims and scope Submit manuscript

Abstract

Background

Cardioversion and catheter-based circumferential pulmonary vein isolation (CPVI) are established rhythm control treatment strategies for patients with atrial fibrillation (AF). However, these treatments are contraindicated for AF patients with a left atrial appendage (LAA) thrombus.

Methods

We conducted the first-in-man case series study to evaluate the feasibility and safety of performing cardioversion or CPVI in AF patients with LAA thrombus immediately after implantation of LAA Occluder (LAAO) in a combined procedure. In our multi-center LAAO registry of 310 patients, 27 symptomatic and drug-refractory AF patients underwent a combined procedure of LAAO and CPVI, among whom 10 (mean age 68 ± 16 years, 6 men) having anticoagulant-resistant LAA thrombus received a bailout procedure of LAAO implantation first then CPVI, and the other 17 patients without LAA thrombus received CPVI first then LAAO for comparison.

Results

The mean CHA2DS2-VASc score and HAS-BLED score were comparable between these two groups. In patients with LAA thrombus, we put carotid filters and did a no-touch technique, neither advancing the wire and sheath into the LAA nor performing LAA angiography. After LAAO implantation, the connecting cable was still connected to the occluder when cardioversion was performed. During CPVI, the occluder location was registered in the LA geometry by three-dimensional mapping to guide the catheter not to touch the LAAO. The procedure was successful in all the patients without intra-procedural complications. After a mean follow-up of 1.7 ± 0.7 years, there was no device embolization, peri-device leak ≧ 5 mm or stroke event in both groups. The AF recurrence rate was also similar between the two groups (P = 0.697).

Conclusion

We demonstrated that cardioversion or CPVI is doable in symptomatic AF patients with LAA thrombus if LAA was occluded ahead as a bailout procedure.

Graphical Abstract

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

AF:

Atrial fibrillation

CPVI:

Circumferential pulmonary vein isolation

ECG:

Electrocardiogram

LAA:

Left atrial appendage

LAAO:

Left atrial appendage occlusion

TEE:

Trans-esophageal echocardiography

References

  1. Lip GYH, Fauchier L, Freedman SB, Van Gelder I, Natale A, Gianni C, Nattel S, Potpara T, Rienstra M, Tse HF, Lane DA (2016) Atrial fibrillation. Nat Rev Dis Primers 2:16016. https://doi.org/10.1038/nrdp.2016.16

    Article  PubMed  Google Scholar 

  2. Rahman F, Kwan GF, Benjamin EJ (2014) Global epidemiology of atrial fibrillation. Nat Rev Cardiol 11:639–654. https://doi.org/10.1038/nrcardio.2014.118

    Article  PubMed  Google Scholar 

  3. Kannel WB, Wolf PA, Benjamin EJ, Levy D (1998) Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol 82(8a):2N-9N. https://doi.org/10.1016/s0002-9149(98)00583-9

    Article  CAS  PubMed  Google Scholar 

  4. Morillo CA, Banerjee A, Perel P, Wood D, Jouven X (2017) Atrial fibrillation: the current epidemic. J Geriatr Cardiol 14:195–203. https://doi.org/10.11909/j.issn.1671-5411.2017.03.011

    Article  PubMed  PubMed Central  Google Scholar 

  5. Hindricks G, Potpara T, Dagres N, ESC Scientific Document Group (2021) 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 42:373–498. doi: https://doi.org/10.1093/eurheartj/ehaa612.

  6. Kong B, Liu Y, Huang H, Jiang H, Huang C (2015) Left atrial appendage closure for thromboembolism prevention in patients with atrial fibrillation: advances and perspectives. J Thorac Dis 7:199–203. https://doi.org/10.3978/j.issn.2072-1439.2015.01.20

    Article  PubMed  PubMed Central  Google Scholar 

  7. Reddy VY, Sievert H, Halperin J, Doshi SK, Buchbinder M, Neuzil P, Huber K, Whisenant B, Kar S, Swarup V, Gordon N, Holmes DPROTECTAF, Committee S, Investigators, (2014) Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation: a randomized clinical trial. JAMA 312:1988–1998. https://doi.org/10.1001/jama.2014.15192

    Article  CAS  PubMed  Google Scholar 

  8. Gangireddy SR, Halperin JL, Fuster V, Reddy VY (2012) Percutaneous left atrial appendage closure for stroke prevention in patients with atrial fibrillation: an assessment of net clinical benefit. Eur Heart J 33:2700–2708. https://doi.org/10.1093/eurheartj/ehs292

    Article  PubMed  Google Scholar 

  9. Reddy VY, Möbius-Winkler S, Miller MA, Neuzil P, Schuler G, Wiebe J, Sick P, Sievert H (2013) Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix feasibility study with watchman left atrial appendage closure technology). J Am Coll Cardiol 61:2551–2556. https://doi.org/10.1016/j.jacc.2013.03.035

    Article  PubMed  Google Scholar 

  10. Boersma LV, Ince H, Kische S, Investigators EWOLUTION et al (2017) Efficacy and safety of left atrial appendage closure with WATCHMAN in patients with or without contraindication to oral anticoagulation: 1-Year follow-up outcome data of the EWOLUTION trial. Heart Rhythm 14:1302–1308. https://doi.org/10.1016/j.hrthm.2017.05.038

    Article  PubMed  Google Scholar 

  11. Tzikas A (2017) Left atrial appendage occlusion with Amplatzer cardiac plug and Amplatzer Amulet: a clinical trials update. J Atr Fibrillation 10:1651. https://doi.org/10.4022/jafib.1651

    Article  PubMed  PubMed Central  Google Scholar 

  12. Osmancik P, Herman D, Neuzil P, PRAGUE-17 Trial Investigators et al (2020) Left atrial appendage closure versus direct oral anticoagulants in high-risk patients with atrial fibrillation. J Am Coll Cardiol 75:3122–3135. https://doi.org/10.1016/j.jacc.2020.04.067

    Article  CAS  PubMed  Google Scholar 

  13. Packer DL, Mark DB, Robb RA, Investigators CABANA et al (2019) Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: The CABANA Randomized Clinical Trial. JAMA 321:1261–1274. https://doi.org/10.1001/jama.2019.0693

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Blomström-Lundqvist C, Gizurarson S, Schwieler J, Jensen SM, Bergfeldt L, Kennebäck G, Rubulis A, Malmborg H, Raatikainen P, Lönnerholm S, Höglund N, Mörtsell D (2019) Effect of catheter ablation vs antiarrhythmic medication on quality of life in patients with atrial fibrillation: The CAPTAF Randomized Clinical Trial. JAMA 321:1059–1068. https://doi.org/10.1001/jama.2019.0335

    Article  PubMed  PubMed Central  Google Scholar 

  15. Van Gelder IC, Tuinenburg AE, Schoonderwoerd BS, Tieleman RG, Crijns HJ (1999) Pharmacologic versus direct-current electrical cardioversion of atrial flutter and fibrillation. Am J Cardiol 84(9A):147R-151R. https://doi.org/10.1016/s0002-9149(99)00715-8

    Article  PubMed  Google Scholar 

  16. Noseworthy PA, Kapa S, Deshmukh AJ, Madhavan M, Van Houten H, Haas LR, Mulpuru SK, McLeod CJ, Asirvatham SJ, Friedman PA, Shah ND, Packer DL (2015) Risk of stroke after catheter ablation versus cardioversion for atrial fibrillation: a propensity-matched study of 24,244 patients. Heart Rhythm 12:1154–1161. https://doi.org/10.1016/j.hrthm.2015.02.020

    Article  PubMed  Google Scholar 

  17. Fatkin D, Kuchar DL, Thorburn CW, Feneley MP (1994) Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for “atrial stunning” as a mechanism of thromboembolic complications. J Am Coll Cardiol 23:307–316. https://doi.org/10.1016/0735-1097(94)90412-x

    Article  CAS  PubMed  Google Scholar 

  18. Fuster V, Rydén LE, Asinger RW et al (2001) ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation): developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 38:1231–1266. https://doi.org/10.1016/s0735-1097(01)01587-x

    Article  CAS  PubMed  Google Scholar 

  19. Hwang J, Park HS, Jun SW, Choi SW, Lee CH, Kim IC, Cho YK, Yoon HJ, Kim H, Nam CW, Hur SH, Lee SH, Han S (2018) The incidence of left atrial appendage thrombi on transesophageal echocardiography after pretreatment with apixaban for cardioversion in the real-world practice. PLoS ONE 13:e0208734. https://doi.org/10.1371/journal.pone.0208734

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Fukuda S, Watanabe H, Shimada K, Aikawa M, Kono Y, Jissho S, Taguchi H, Umemura J, Yoshiyama M, Shiota T, Sumiyoshi T, Yoshikawa J (2011) Left atrial thrombus and prognosis after anticoagulation therapy in patients with atrial fibrillation. J Cardiol 58:266–277. https://doi.org/10.1016/j.jjcc.2011.06.009

    Article  PubMed  Google Scholar 

  21. Sharma SP, Cheng J, Turagam MK, Gopinathannair R, Horton R, Lam YY, Tarantini G, D’Amico G, Rofastes XF, Lange M, Natale A, Lakkireddy DR (2020) Feasibility of left atrial appendage occlusion in left atrial appendage thrombus: a systematic review. JACC Clin Electrophysiol 6:414–424. https://doi.org/10.1016/j.jacep.2019.11.017

    Article  PubMed  Google Scholar 

  22. Saito S, Shindo S, Tsudaka S, Uchida K, Shirakawa M, Yoshimura S (2016) Resolving thrombus in the left atrial appendage by edoxaban treatment after acute ischemic stroke: report of 2 Cases. J Stroke Cerebrovasc Dis 25:e188–e191. https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.07.036

    Article  PubMed  Google Scholar 

  23. Farkowski MM, Jubele K, Marín F, Gandjbakhch E, Ptaszynski P, Merino JL, Lenarczyk R, Potpara TS (2020) Diagnosis and management of left atrial appendage thrombus in atients with atrial fibrillation undergoing cardioversion or percutaneous left atrial procedures: results of the European Heart Rhythm Association survey. Europace 22:162–169. https://doi.org/10.1093/europace/euz257

    Article  PubMed  Google Scholar 

  24. Faggiano P, Dinatolo E, Moreo A et al (2022) Prevalence and rate of resolution of left atrial thrombus in patients with non-valvular atrial fibrillation: a two-center retrospective real-world study. J Clin Med 11:1520. https://doi.org/10.3390/jcm11061520

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Nelles D, Lambers M, Schafigh M et al (2021) Clinical outcomes and thrombus resolution in patients with solid left atrial appendage thrombi: results of a single-center real-world registry. Clin Res Cardiol 110:72–83. https://doi.org/10.1007/s00392-020-01651-8

    Article  CAS  PubMed  Google Scholar 

  26. Niku AD, Shiota T, Siegel RJ, Rader F (2019) Prevalence and resolution of left atrial thrombus in patients with nonvalvular atrial fibrillation and flutter with oral anticoagulation. Am J Cardiol 123:63–68. https://doi.org/10.1016/j.amjcard.2018.09.027

    Article  PubMed  Google Scholar 

  27. Marrouche NF, Brachmann J, Andresen D, Investigators CASTLE-AF et al (2018) Catheter ablation for atrial fibrillation with heart failure. New Engl J Med 378:417–427. https://doi.org/10.1056/NEJMoa1707855

    Article  PubMed  Google Scholar 

  28. Packer DL, Piccini JP, Monahan KH, Al-Khalidi HR, Silverstein AP, Noseworthy PA, Poole JE, Bahnson TD, Lee KL, Mark DB, Investigators CABANA (2021) Ablation versus drug therapy for atrial fibrillation in heart failure: results from the CABANA Trial. Circulation 143:1377–1390. https://doi.org/10.1161/CIRCULATIONAHA.120.050991

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Hunter RJ, Berriman TJ, Diab I et al (2014) A randomized controlled trial of catheter ablation versus medical treatment of atrial fibrillation in heart failure (the CAMTAF trial). Circ Arrhythm Electrophysiol 7:31–38. https://doi.org/10.1161/CIRCEP.113.000806

    Article  CAS  PubMed  Google Scholar 

  30. Khan AR, Khan S, Sheikh MA, Khuder S, Grubb B, Moukarbel GV (2014) Catheter ablation and antiarrhythmic drug therapy as first- or second-line therapy in the management of atrial fibrillation: systematic review and meta-analysis. Circ Arrhythm Electrophysiol 7:853–860. https://doi.org/10.1161/CIRCEP.114.001853

    Article  CAS  PubMed  Google Scholar 

  31. Andrade JG, Wells GA, Deyell MW, Investigatos EARLY-AF et al (2021) Cryoablation or drug therapy for Initial treatment of atrial fibrillation. New Engl J Med 384:305–315. https://doi.org/10.1056/NEJMoa2029980

    Article  CAS  PubMed  Google Scholar 

  32. Tarantini G, D’Amico G, Latib A, Montorfano M, Mazzone P, Fassini G, Maltagliati A, Ronco F, Sacca S, Cruz-Gonzalez I, Ibrahim R, Freixa X (2018) Percutaneous left atrial appendage occlusion in patients with atrial fibrillation and left appendage thrombus: feasibility, safety and clinical efficacy. EuroIntervention 13:1595–1602. https://doi.org/10.4244/EIJ-D-17-00777

    Article  PubMed  Google Scholar 

  33. Akyüz Ş, Avcı II, Karabay CY, Genç D, Palice A (2020) How to safely occlude left atrial appendage with a thrombus inside? Anatol J Cardiol 23:49–52. https://doi.org/10.14744/AnatolJCardiol.2019.02222

    Article  PubMed  PubMed Central  Google Scholar 

  34. Meincke F, Spangenberg T, Kreidel F, Frerker C, Virmani R, Ladich E, Kuck KH, Ghanem A (2017) Rationale of cerebral protection devices in left atrial appendage occlusion. Catheter Cardiovasc Interv 891:154–158. https://doi.org/10.1002/ccd.26677

    Article  Google Scholar 

  35. Pietrasik GM, Huang HD, Rodriguez JM, Sharma PS, Trohman RG, Krishnan K (2020) Safety and feasibility of radiofrequency redo pulmonary vein isolation ablation for atrial fibrillation after Amulet implantation and device electrical characteristics. Heart Rhythm Case Rep 6:415–418. https://doi.org/10.1016/j.hrcr.2020.03.019

    Article  Google Scholar 

  36. Wintgens L, Romanov A, Phillips K, Ballesteros G, Swaans M, Folkeringa R, Garcia-Bolao I, Pokushalov E, Boersma L (2018) Combined atrial fibrillation ablation and left atrial appendage closure: long-term follow-up from a large multicentre registry. Europace 20:1783–1789. https://doi.org/10.1093/europace/euy025

    Article  PubMed  Google Scholar 

  37. Alipour A, Swaans MJ, van Dijk VF, Balt JC, Post MC, Bosschaert MAR, Rensing BJ, Reddy VY, Boersma LVA (2015) Ablation for atrial fibrillation combined with left atrial appendage closure. JACC Clin Electrophysiol 1:486–495. https://doi.org/10.1016/j.jacep.2015.07.009

    Article  PubMed  Google Scholar 

  38. Walker DT, Phillips KP (2015) Left atrial catheter ablation subsequent to Watchman® left atrial appendage device implantation: a single centre experience. Europace 17:1402–1406. https://doi.org/10.1093/europace/euv037

    Article  PubMed  Google Scholar 

  39. Turagam MK, Lavu M, Afzal MR et al (2017) Catheter ablation for atrial fibrillation in patients with Watchman left atrial appendage occlusion device: results from a multicenter registry. J Cardiovasc Electrophysiol 28:139–146. https://doi.org/10.1111/jce.13148

    Article  PubMed  Google Scholar 

  40. Aminian A, Schmidt B, Mazzone P et al (2019) Incidence, characterization, and clinical impact of device-related thrombus following left atrial appendage occlusion in the prospective global AMPLATZER Amulet observational study. JACC Cardiovasc Interv 12:1003–1014. https://doi.org/10.1016/j.jcin.2019.02.003

    Article  PubMed  Google Scholar 

  41. Spencer RJ, DeJong P, Fahmy P, Lempereur M, Tsang MYC, Gin KG, Lee PK, Nair P, Tsang TSM, Jue J, Saw J (2015) Changes in left atrial appendage dimensions following volume loading during percutaneous left atrial appendage closure. JACC Cardiovasc Interv 8:1935–1941. https://doi.org/10.1016/j.jcin.2015.07.035

    Article  PubMed  Google Scholar 

  42. Phillips KP, Romanov A, Artemenko S, Folkeringa RJ, Szili-Torok T, Senatore G, Stein KM, Razali O, Gordon N, Boersma LVA (2020) Combining left atrial appendage closure and catheter ablation for atrial fibrillation: 2-year outcomes from a multinational registry. Europace 22:225–231. https://doi.org/10.1093/europace/euz286

    Article  PubMed  Google Scholar 

  43. Sharma SP, Turagam MK, Gopinathannair R, Reddy V, Kar S, Mohanty S, Cheng J, Holmes DR Jr, Sondergaard L, Natale A, Lakkireddy D (2019) Direct current cardioversion of atrial fibrillation in patients with left atrial appendage occlusion devices. J Am Coll Cardiol 74:2267–2274. https://doi.org/10.1016/j.jacc.2019.08.1045

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

None to be declared.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Chia-Ti Tsai.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tsai, CF., Huang, PS., Chiu, FC. et al. Bailout left atrial appendage occluder for pulmonary vein isolation and electrical cardioversion in patients with atrial fibrillation and left atrial appendage thrombus: a pilot study. Clin Res Cardiol 112, 772–783 (2023). https://doi.org/10.1007/s00392-022-02085-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00392-022-02085-0

Keywords

Navigation